Failure to Perform and Document Diabetic Foot Checks
Penalty
Summary
The facility failed to ensure that residents with diabetes mellitus received routine diabetic foot checks in accordance with professional standards of practice. Three residents with diabetes, each with additional risk factors such as diabetic neuropathy, chronic kidney disease, and polyneuropathy, did not have documentation of daily diabetic foot checks in their medical records. The care plans for these residents either lacked specific interventions for daily foot checks or did not address foot checks at all, despite the presence of diabetes and related complications. Interviews with nursing staff, including a Registered Nurse/Unit Manager, revealed that only weekly skin checks were performed during shower checks, and daily diabetic foot checks were not conducted or documented. The staff indicated that Certified Nursing Assistants were expected to document these checks, but no evidence of such documentation was found for the residents in question. When asked, the staff confirmed that daily foot checks for residents with diabetes were not part of their routine practice. The facility's own Skin Integrity-Foot Care policy requires foot care and treatment to be provided in accordance with professional standards, including systematic prevention and management of foot ulcers and regular monitoring. However, the policy was not followed for the residents identified, as there was no documentation or evidence of daily diabetic foot checks being completed. The deficiency was confirmed through record review and staff interviews, with no additional information provided by the facility to explain the lack of compliance.